Common use of Eligible Populations Clause in Contracts

Eligible Populations. The Demonstration will be available to individuals who meet all of the following criteria: • Age 21 and older at the time of enrollment; • Entitled to benefits under Medicare Part A and enrolled under Medicare Parts B and D, and receiving full Medicaid benefits; and • Enrolled in the Medicaid Aid to the Aged, Blind, and Disabled (AABD) category of assistance. Eligible populations include: • Beneficiaries who meet all other Demonstration criteria and are in the following Medicaid 1915(c) waivers: o Persons who are Elderly; o Persons with Disabilities; o Persons with HIV/AIDS; o Persons with Brain Injury and o Persons residing in Supportive Living Facilities. • Individuals with End Stage Renal Disease (ESRD) at the time of enrollment. The following populations will be excluded from enrollment: • Individuals under the age of 21; • Individuals receiving developmental disability institutional services or who participate in the HCBS waiver for Adults with Developmental Disabilities; • The Medicaid Spend-down population; • Beneficiaries in the Illinois Medicaid Breast and Cervical Cancer program; • Individuals enrolled in partial benefit programs; and • Individuals enrolled in both Medicare and Medicaid who have Comprehensive Third Party Insurance. Medicare-Medicaid beneficiaries who are in Medicare fee-for-service and meet the eligibility criteria above will be eligible for Passive Enrollment beginning January 1, 2014, unless they elect to opt out of the Demonstration, as discussed in C.2 below. Those beneficiaries who are enrolled in a Medicare Advantage plan that is operated by the same parent organization that operates a Demonstration Plan will also be eligible for Passive Enrollment into the Demonstration Plan operated by the same parent organization beginning January 1, 2014. Eligible beneficiaries enrolled in a Medicare Advantage plan that is operated by a parent organization that is not offering a Demonstration Plan may enroll into the Demonstration if they elect to disenroll from their current Medicare Advantage plan.

Eligible Populations. The Demonstration will be available to individuals who meet all of the following criteria: •  Age 21 and older at the time of enrollment; •  Entitled to benefits under Medicare Part A and enrolled under Medicare Parts B and D, and receiving full Medicaid benefits; and •  Enrolled in the Medicaid Aid to the Aged, Blind, and Disabled (AABD) category of assistance. Eligible populations include: •  Beneficiaries who meet all other Demonstration criteria and are in the following Medicaid 1915(c) waivers: o Persons who are Elderly; o Persons with Disabilities; o Persons with HIV/AIDS; o Persons with Brain Injury and o Persons residing in Supportive Living Facilities. •  Individuals with End Stage Renal Disease (ESRD) at the time of enrollment. The following populations will be excluded from enrollment: •  Individuals under the age of 21; •  Individuals receiving developmental disability institutional services or who participate in the HCBS waiver for Adults with Developmental Disabilities; •  The Medicaid Spend-down population; •  Beneficiaries in the Illinois Medicaid Breast and Cervical Cancer program; •  Individuals enrolled in partial benefit programs; and •  Individuals enrolled in both Medicare and Medicaid who have Comprehensive Third Party Insurance. Medicare-Medicaid beneficiaries who are in Medicare fee-for-service and meet the eligibility criteria above will be eligible for Passive Enrollment beginning January 1, 2014, unless they elect to opt out of the Demonstration, as discussed in C.2 below. Those beneficiaries who are enrolled in a Medicare Advantage plan that is operated by the same parent organization that operates a Demonstration Plan will also be eligible for Passive Enrollment into the Demonstration Plan operated by the same parent organization beginning January 1, 2014. Eligible beneficiaries enrolled in a Medicare Advantage plan that is operated by a parent organization that is not offering a Demonstration Plan may enroll into the Demonstration if they elect to disenroll from their current Medicare Advantage plan.

Eligible Populations. The Demonstration will be available to individuals who meet all of the following criteria: • Age 21 and or older at the time of enrollment; • Entitled to benefits under Medicare Part A and enrolled under Medicare Parts B and D, and receiving full Medicaid benefits; • Required to receive their Medicaid benefits through the STAR+PLUS program as further outlined in the state’s existing THTQIP section 1115(a) demonstration. Generally, these are individuals who are age 21 or older who: o have a physical disability or a mental disability and qualify for SSI, or o qualify for Medicaid because they receive Home and Community Based Services (HCBS) STAR+PLUS Waiver services; and • Enrolled Reside in one of the Medicaid Aid to Demonstration counties listed in Appendix 3. Dually eligible individuals residing in Intermediate Care Facilities for Individuals with Intellectual Disabilities and Related Conditions (ICF/IIDs) or receiving services through the Aged, Blind, and Disabled (AABDfollowing section 1915(c) category of assistance. Eligible populations includewaivers will be excluded from the Demonstration: • Beneficiaries who meet all other Demonstration criteria Community Living Assistance and are in the following Medicaid 1915(cSupport Services (CLASS) waivers: o Persons who are Elderly; o Persons • Deaf Blind with Disabilities; o Persons with HIV/AIDS; o Persons with Brain Injury Multiple Disabilities Program (DBMD) • Home and o Persons residing in Supportive Community-based Services (HSC) • Texas Home Living Facilities. • Individuals with End Stage Renal Disease Program (ESRDTxHmL) at the time of enrollment. The following populations will be excluded from enrollmentpassive enrollment in the Demonstration but may elect to enroll under the following circumstances: • Individuals under the age of 21; • Individuals receiving developmental disability institutional services or who participate in the HCBS waiver for Adults with Developmental Disabilities; • The Medicaid Spend-down population; • Beneficiaries in the Illinois Medicaid Breast and Cervical Cancer program; • Individuals enrolled in partial benefit programs; and • Individuals enrolled in both Medicare and Medicaid who have Comprehensive Third Party Insurance. Medicare-Medicaid beneficiaries who are in Medicare fee-for-service and meet the eligibility criteria above will be eligible for Passive Enrollment beginning January 1, 2014, unless they elect to opt out of the Demonstration, as discussed in C.2 below. Those beneficiaries who are enrolled in a Medicare Advantage plan that is not operated by the same parent organization that operates a Demonstration Plan will also be eligible STAR+PLUS MMP and who meet the eligibility criteria for Passive Enrollment into the Demonstration Plan operated by the same parent organization beginning January 1, 2014. Eligible beneficiaries enrolled may enroll in a Medicare Advantage plan that is operated by a parent organization that is not offering a Demonstration Plan may enroll into the Demonstration STAR+PLUS MMP if they elect to disenroll from their current Medicare Advantage existing plan; • Individuals enrolled in the Program of All-Inclusive Care for the Elderly (PACE) who meet the eligibility criteria for the Demonstration may enroll in if they disenroll from that program; and • Eligible individuals participating in the CMS Independence at Home (IAH) demonstration may enroll in the Demonstration if they disenroll from IAH.

Eligible Populations. The Demonstration will be available to individuals who meet all of the following criteria: • Age 21 65 and older at the time of enrollment; and • Entitled to benefits under Medicare Part A and A, enrolled under in Medicare Parts B and D, and receiving full Medicaid benefits; and • Enrolled . This includes individuals enrolled in the Medicaid Aid to the AgedCommunity Choices Waiver, Blind, and Disabled (AABD) category of assistance. Eligible populations include: • Beneficiaries who meet all other Demonstration criteria and are in the following Medicaid 1915(c) waivers: o Persons who are Elderly; o Persons with Disabilities; o Persons with HIV/AIDS; o Persons with Brain Injury AIDS Waiver and o Persons residing in Supportive Living Facilities. • Individuals with End Stage Renal Disease (ESRD) at the time of enrollmentMechanical Ventilation Waiver. The following populations are not eligible for the Demonstration and will be excluded from enrollment: • Individuals under the age of 21; • Individuals receiving developmental disability institutional services or who participate in the HCBS waiver for Adults with Developmental Disabilities65; • The Medicaid Spendspend-down population; • Beneficiaries in the Illinois Medicaid Breast and Cervical Cancer program; • Individuals enrolled in partial benefit programs; and • Individuals enrolled in both Medicare and Medicaid who have Comprehensive Third Party Insurance. Medicare-Medicaid beneficiaries ; • Individuals residing in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) or Nursing Facility at the time of Demonstration eligibility determination; • Individuals who are in Medicare feea hospice program or are receiving End-for-service Stage Renal Disease (ESRD) services at the time of Demonstration eligibility determination; and meet • Individuals who are participating in federal waiver programs for home and community based Medicaid coverage other that the eligibility criteria above will be eligible for Passive Enrollment beginning January 1Community Choices Waiver, 2014HIV/AIDS Waiver and Mechanical Ventilation Waiver (e.g., unless they Intellectual Disabilities and Related Disabilities Waiver, Head and Spinal Cord Injury Waiver, Community Supports Waiver, Medically Complex Children’s Waiver, Pervasive Developmental Disorder Waiver and Psychiatric Residential Treatment Facility Alternative CHANCE Waiver.) Individuals may elect to opt out of enroll or remain in the Demonstration, as discussed in C.2 below. Those beneficiaries who are Demonstration under the following circumstances: • Individuals enrolled in a Medicare Advantage plan that is operated by or Program of All-inclusive Care for the same parent organization that operates a Elderly (PACE) and who meet the eligibility criteria for this Demonstration Plan will also be eligible for Passive Enrollment into the Demonstration Plan operated by the same parent organization beginning January 1, 2014. Eligible beneficiaries enrolled may participate in a Medicare Advantage plan that is operated by a parent organization that is not offering a Demonstration Plan may enroll into the Demonstration this initiative if they elect choose to disenroll from their current Medicare Advantage planexisting programs. • Individuals who transition from a Nursing Facility or ICF/IID into the community and are otherwise eligible for Demonstration participation may elect to enroll in the Demonstration. (Note that once these individuals are transitioned into the community they may be eligible for passive enrollment.) • Individuals already enrolled who later enter a Nursing Facility may remain in the Demonstration. • Individuals already enrolled in the Demonstration who enter hospice programs or become eligible for ESRD services may remain in the Demonstration.

Eligible Populations. The Demonstration will be available to individuals who meet all of the following criteria: •  Age 21 65 and older at the time of enrollment; • and  Entitled to benefits under Medicare Part A and A, enrolled under in Medicare Parts B and D, and receiving full Medicaid benefits; and • Enrolled . This includes individuals enrolled in the Medicaid Aid to the AgedCommunity Choices Waiver, Blind, and Disabled (AABD) category of assistance. Eligible populations include: • Beneficiaries who meet all other Demonstration criteria and are in the following Medicaid 1915(c) waivers: o Persons who are Elderly; o Persons with Disabilities; o Persons with HIV/AIDS; o Persons with Brain Injury AIDS Waiver and o Persons residing in Supportive Living Facilities. • Individuals with End Stage Renal Disease (ESRD) at the time of enrollmentMechanical Ventilation Waiver. The following populations are not eligible for the Demonstration and will be excluded from enrollment: •  Individuals under the age of 2165; • Individuals receiving developmental disability institutional services or who participate in the HCBS waiver for Adults with Developmental Disabilities; •  The Medicaid Spendspend-down population; • Beneficiaries in the Illinois Medicaid Breast and Cervical Cancer program; • Individuals enrolled in partial benefit programs; and •  Individuals enrolled in both Medicare and Medicaid who have Comprehensive Third Party Insurance. Medicare-Medicaid beneficiaries ;  Individuals residing in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) or Nursing Facility at the time of Demonstration eligibility determination;  Individuals who are in Medicare feea hospice program or are receiving End-for-service Stage Renal Disease (ESRD) services at the time of Demonstration eligibility determination; and meet  Individuals who are participating in federal waiver programs for home and community based Medicaid coverage other that the eligibility criteria above will be eligible for Passive Enrollment beginning January 1Community Choices Waiver, 2014HIV/AIDS Waiver and Mechanical Ventilation Waiver (e.g., unless they Intellectual Disabilities and Related Disabilities Waiver, Head and Spinal Cord Injury Waiver, Community Supports Waiver, Medically Complex Children’s Waiver, Pervasive Developmental Disorder Waiver and Psychiatric Residential Treatment Facility Alternative CHANCE Waiver.) Individuals may elect to opt out of enroll or remain in the Demonstration, as discussed in C.2 below. Those beneficiaries who are Demonstration under the following circumstances:  Individuals enrolled in a Medicare Advantage plan that is operated by or Program of All-inclusive Care for the same parent organization that operates a Elderly (PACE) and who meet the eligibility criteria for this Demonstration Plan will also be eligible for Passive Enrollment into the Demonstration Plan operated by the same parent organization beginning January 1, 2014. Eligible beneficiaries enrolled may participate in a Medicare Advantage plan that is operated by a parent organization that is not offering a Demonstration Plan may enroll into the Demonstration this initiative if they elect choose to disenroll from their current Medicare Advantage planexisting programs.  Individuals who transition from a Nursing Facility or ICF/IID into the community and are otherwise eligible for Demonstration participation may elect to enroll in the Demonstration. (Note that once these individuals are transitioned into the community they may be eligible for passive enrollment.)  Individuals already enrolled who later enter a Nursing Facility may remain in the Demonstration.  Individuals already enrolled in the Demonstration who enter hospice programs or become eligible for ESRD services may remain in the Demonstration.

Eligible Populations. The ICI Demonstration will be available to individuals who meet all of the following criteria: • Age 21 and older at the time of enrollment; • Entitled to benefits under Medicare Part A and enrolled under Medicare Parts B and D, and receiving full Medicaid benefits, including: long-term nursing facility residents; individuals with intellectual and developmental disabilities; individuals with Serious and Persistent Mental Illness; individuals eligible for LTSS in the community; individuals residing in the community without LTSS needs; and • Enrolled in the Medicaid Aid to the Aged, Blind, and Disabled (AABD) category of assistance. Eligible populations include: • Beneficiaries who meet all other Demonstration criteria and are in the following Medicaid 1915(c) waivers: o Persons who are Elderly; o Persons with Disabilities; o Persons with HIV/AIDS; o Persons with Brain Injury and o Persons residing in Supportive Living Facilities. • Individuals individuals with End Stage Renal Disease (ESRD) at the time of enrollment; and • Age 21 or greater at the time of eligibility determination. The following populations are not eligible for the ICI Demonstration: • Medicare beneficiaries who are not eligible for full Medicaid benefits, including Qualified Medicare Beneficiaries (QMBs), Specified Low-Income Beneficiaries (SLMBs), and Qualifying Individuals (QIs); • Individuals who are eligible for “partial” Medicare: benefits (Part A only or Part B/D only); • Individuals who are required to “spend down” income in order to meet Medicaid eligibility requirements, and who are not eligible for LTSS; • Individuals residing at Xxxxxxx, Xxxxxxx Xxxxxx, or out-of state hospitals; • Individuals eligible for the Medicaid buy-in for workers with disabilities and meet a nursing facility level of care (in Rhode Island this is called The Sherlock Plan); • Individuals who are in hospice on the effective enrollment date. Enrollees who elect hospice care while enrolled in an MMP can remain in the MMP; and • Individuals who reside out of state (e.g., an individual who is admitted to an out-of- state nursing facility). The following individuals may elect to enroll and participate in the Demonstration, but will not be excluded from enrollmentpassively enrolled: • Individuals under the age of 21; • Individuals receiving developmental disability institutional services with active comprehensive commercial or who participate in the HCBS waiver for Adults with Developmental Disabilities; • The Medicaid Spend-down population; • Beneficiaries in the Illinois Medicaid Breast and Cervical Cancer program; • Individuals enrolled in partial benefit programsother coverage, including employer, union, or TRICARE coverage; and • Individuals enrolled in both Medicare and Medicaid who have Comprehensive Third Party Insurancethe Program of All-Inclusive Care for the Elderly (PACE). Medicare-Medicaid beneficiaries who are These individuals may enroll in Medicare fee-for-service and meet the eligibility criteria above will be eligible for Passive Enrollment beginning January 1, 2014, unless Demonstration if they elect choose to opt out of the Demonstration, as discussed in C.2 belowdisenroll from PACE. Those beneficiaries who are enrolled in a Medicare Advantage plan that is operated by the same parent organization that operates a Demonstration Plan an MMP will also be eligible for Passive Enrollment passive enrollment into the Demonstration Plan MMP operated by the same parent organization beginning January 1, 2014organization. Eligible beneficiaries enrolled in a Medicare Advantage plan that is operated by a parent organization that is not offering a Demonstration Plan an MMP will not be passively enrolled. They may enroll into in the ICI Demonstration if they elect to disenroll from their current Medicare Advantage plan.

Eligible Populations. The FIDA Demonstration will be available to individuals who meet all of the following criteria: • Age 21 and or older at the time of enrollment; • Entitled to benefits under Medicare Part A and enrolled under Medicare Parts B and D, and receiving full Medicaid benefits; and • Enrolled Reside in a FIDA Demonstration county. Individuals must also meet one of the Medicaid Aid three following criteria: • Are Nursing Facility Clinically Eligible and receiving facility-based long-term services and supports (LTSS), which are subsequently referred to as individuals eligible for facility-based LTSS. These individuals are eligible contingent upon submission and approval of an amendment to the Aged, Blind, and Disabled existing Partnership Plan demonstration under Social Security Act Section 1115(a); • Are eligible for the Nursing Home Transition & Diversion (AABDNHTD) category of assistance. Eligible populations include: • Beneficiaries who meet all other Demonstration criteria and are in the following Medicaid 1915(c) waivers: o Persons who are Elderlywaiver contingent upon submission and approval of an amendment to the existing Partnership Plan demonstration under Social Security Act Section 1115(a) and an amendment to the NHTD Section 1915(c) waiver; o Persons or • Require community-based long term care services for more than 120 days. Assessments to identify an individual’s need for 120 days or more of community- based long term care services shall be conducted in accordance with Disabilities; o Persons with HIV/AIDS; o Persons with Brain Injury Special Term and o Persons residing in Supportive Living Facilities. • Individuals with End Stage Renal Disease (ESRD) at Condition 28 of the time of enrollmentPartnership Plan Demonstration under Social Security Act Section 1115(a). The following populations will be excluded are not eligible for the FIDA Demonstration: • Residents of a New York State Office of Mental Health (OMH) facility; • Those receiving services from enrollment: the New York State Office for People with Developmental Disabilities (OPWDD) system; • Individuals under the age of 21; • Residents of psychiatric facilities; • Individuals expected to be Medicaid eligible for less than six months; • Individuals eligible for Medicaid benefits only with respect to tuberculosis-related services; • Individuals with a "county of fiscal responsibility" code 99 in MMIS (individuals eligible only for breast and cervical cancer services); • Individuals receiving developmental disability institutional hospice services (at time of enrollment); • Individuals with a "county of fiscal responsibility" code of 97 (individuals residing in a State Office of Mental Health facility); • Individuals with a “county of fiscal responsibility” code of 98 (individuals in an OPWDD facility or who participate treatment center); • Individuals eligible for the family planning expansion program; • Individuals under 65 years of age (screened and require treatment) in the HCBS waiver Centers for Adults with Developmental DisabilitiesDisease Control and Prevention breast and/or cervical cancer early detection program and need treatment for breast or cervical cancer, and are not otherwise covered under creditable health coverage; • The Medicaid Spend-down populationResidents of intermediate care facilities for individuals with intellectual/developmental disabilities (ICF/IIDD); • Beneficiaries Individuals who could otherwise reside in an ICF/IIDD, but choose not to; • Residents of alcohol/substance abuse long-term residential treatment programs; • Individuals eligible for Emergency Medicaid; • Individuals in the Illinois OPWDD Home- and Community-Based Services (OPWDD HCBS) section 1915(c) waiver program; • Individuals in the following section 1915(c) waiver program: Traumatic Brain Injury (TBI); • Residents of Assisted Living Programs; and • Individuals in the Xxxxxx Family Care Demonstration. The following individuals will be excluded from passive enrollment: • Native Americans but they may opt in to the Demonstration at any time; • Individuals who are eligible for the Medicaid Breast buy-in for the working disabled and Cervical Cancer programare nursing home certifiable; • Aliessa Court Ordered Individuals; • Individuals enrolled in partial benefit programsPACE; • Individuals enrolled in a Medicare Advantage Special Needs Plan for institutionalized individuals; • Individuals enrolled in Health Homes; • Individuals assigned to a CMS Accountable Care Organization (ACO) as of the point in time they would otherwise be included in the passive enrollment phase; • Individuals participating in the CMS Independence at Home demonstration; and • Individuals enrolled in both Medicare and Medicaid who have Comprehensive Third Party Insurance. Medicare-Medicaid beneficiaries who are in Medicare fee-for-service and meet the eligibility criteria above will be eligible Employer or Union Sponsored coverage for Passive Enrollment beginning January 1, 2014, unless they elect to opt out of the Demonstration, as discussed in C.2 below. Those beneficiaries who are enrolled in a Medicare Advantage plan that is operated by the same parent organization that operates a Demonstration Plan will also be eligible for Passive Enrollment into the Demonstration Plan operated by the same parent organization beginning January 1, 2014. Eligible beneficiaries enrolled in a Medicare Advantage plan that is operated by a parent organization that is not offering a Demonstration Plan may enroll into the Demonstration if they elect to disenroll from their current Medicare Advantage planemployees or retirees.

Eligible Populations. The Demonstration will be available to individuals who meet all of the following criteria: • Age  Individuals age 21 and older at the time of enrollment; • Entitled entitled to benefits under Medicare Part A and enrolled under Medicare Parts B and D, and receiving full Medicaid benefits; and • Enrolled  Reside in one of the Medicaid Aid to the Aged, Blind, and Disabled (AABD) category of assistancetwo Demonstration counties – King County or Snohomish County. Eligible populations include: • Beneficiaries  Enrollees who meet all other Demonstration criteria and are who are: o Participating in the following Aging and Long-Term Support Administration (ALTSA) Community Options Program Entry System (XXXXX) Home and Community-Based Services (HCBS) Medicaid 1915(c) waivers: o Persons who are Elderlywaiver; o Persons Receiving Medicaid Personal Care Services, including those individuals with Disabilitiesdevelopmental disabilities; o Persons with HIV/AIDS; o Persons with Brain Injury and o Persons residing in Supportive Living Facilities. •  Individuals with End Stage Renal Disease (ESRD) at the time of enrollment. The following populations will be excluded from enrollment: • Individuals under the age of 21); • Individuals receiving developmental disability institutional services or who participate in the HCBS waiver for Adults with Developmental Disabilities; • The Medicaid Spend-down population; • Beneficiaries in the Illinois Medicaid Breast and Cervical Cancer program; •  Individuals enrolled in partial benefit programs; and • Individuals enrolled in both Medicare and Medicaid who have Comprehensive Third Party Insurance. Medicare-Medicaid beneficiaries who are in Medicare fee-for-service and meet the eligibility criteria above will be eligible for Passive Enrollment beginning January 1, 2014, unless they elect to opt out of the Demonstration, as discussed in C.2 below. Those beneficiaries who are enrolled in Advantage (including a Medicare Advantage plan Special Needs Plan) that is operated by the same parent organization that operates as a Demonstration Plan MMIP; and  American Indians/Alaska Natives (will also not be passively enrolled). Individuals who meet at least one of the exclusion criteria listed below are not eligible and shall be excluded from enrollment in the Demonstration:  Individuals with developmental disabilities who receive institutional services in Residential Habilitation Centers or Community Intermediate Care Facilities for Passive Enrollment into Individuals with Intellectual Disabilities or who participate in the Developmental Disabilities Administration (DDA) HCBS waiver for Adults and Children with Developmental Disabilities;  Individuals participating in the Money Follows the Person program;  Individuals enrolled in a Program of All-Inclusive Care for the Elderly (PACE). However, PACE participants may enroll in the Demonstration Plan operated by if they choose to disenroll from their PACE provider and enroll in the same parent organization beginning January 1Demonstration;  Individuals enrolled in a hospice program. Individuals receiving hospice services at the time of enrollment will be excluded from the Demonstration. If an individual enters a hospice program while enrolled in the Demonstration, 2014. Eligible beneficiaries he/she will remain in the Demonstration unless he/she disenrolls;  Individuals enrolled in a Medicare Advantage plan Plan that is operated by a parent organization that is not offering a Demonstration Plan MMIP. Such individuals may enroll into the Demonstration if they elect to disenroll from their current Medicare Advantage planPlan;  The Medicaid Spend-down population who meet the criteria for SLMB Plus;  Individuals with other comprehensive Third Party Insurance; and  Individuals residing outside of the Demonstration counties.

Eligible Populations. The FIDA Demonstration will be available to individuals who meet all of the following criteria: •  Age 21 and or older at the time of enrollment; •  Entitled to benefits under Medicare Part A and enrolled under Medicare Parts B and D, and receiving full Medicaid benefits; and • Enrolled  Reside in a FIDA Demonstration county. Individuals must also meet one of the Medicaid Aid three following criteria:  Are Nursing Facility Clinically Eligible and receiving facility-based long-term services and supports (LTSS), which are subsequently referred to as individuals eligible for facility-based LTSS. These individuals are eligible contingent upon submission and approval of an amendment to the Aged, Blind, and Disabled existing Partnership Plan demonstration under Social Security Act Section 1115(a);  Are eligible for the Nursing Home Transition & Diversion (AABDNHTD) category of assistance. Eligible populations include: • Beneficiaries who meet all other Demonstration criteria and are in the following Medicaid 1915(c) waivers: o Persons who are Elderlywaiver contingent upon submission and approval of an amendment to the existing Partnership Plan demonstration under Social Security Act Section 1115(a) and an amendment to the NHTD Section 1915(c) waiver; o Persons or  Require community-based long term care services for more than 120 days. Assessments to identify an individual’s need for 120 days or more of community- based long term care services shall be conducted in accordance with Disabilities; o Persons with HIV/AIDS; o Persons with Brain Injury Special Term and o Persons residing in Supportive Living Facilities. • Individuals with End Stage Renal Disease (ESRD) at Condition 28 of the time of enrollmentPartnership Plan Demonstration under Social Security Act Section 1115(a). The following populations will be excluded are not eligible for the FIDA Demonstration:  Residents of a New York State Office of Mental Health (OMH) facility;  Those receiving services from enrollment: • the New York State Office for People with Developmental Disabilities (OPWDD) system;  Individuals under the age of 21; •  Residents of psychiatric facilities;  Individuals expected to be Medicaid eligible for less than six months;  Individuals eligible for Medicaid benefits only with respect to tuberculosis-related services;  Individuals with a "county of fiscal responsibility" code 99 in MMIS (individuals eligible only for breast and cervical cancer services);  Individuals receiving developmental disability institutional hospice services (at time of enrollment);  Individuals with a "county of fiscal responsibility" code of 97 (individuals residing in a State Office of Mental Health facility);  Individuals with a “county of fiscal responsibility” code of 98 (individuals in an OPWDD facility or who participate treatment center);  Individuals eligible for the family planning expansion program;  Individuals under 65 years of age (screened and require treatment) in the HCBS waiver Centers for Adults Disease Control and Prevention breast and/or cervical cancer early detection program and need treatment for breast or cervical cancer, and are not otherwise covered under creditable health coverage;  Residents of intermediate care facilities for individuals with Developmental Disabilitiesintellectual/developmental disabilities (ICF/IIDD); • The Medicaid Spend Individuals who could otherwise reside in an ICF/IIDD, but choose not to;  Residents of alcohol/substance abuse long-down populationterm residential treatment programs; • Beneficiaries  Individuals eligible for Emergency Medicaid;  Individuals in the Illinois Medicaid Breast OPWDD Home- and Cervical Cancer Community-Based Services (OPWDD HCBS) section 1915(c) waiver program; •  Individuals in the following section 1915(c) waiver program: Traumatic Brain Injury (TBI);  Residents of Assisted Living Programs; and  Individuals in the Xxxxxx Family Care Demonstration. The following individuals will be excluded from passive enrollment:  Native Americans but they may opt in to the Demonstration at any time;  Individuals who are eligible for the Medicaid buy-in for the working disabled and are nursing home certifiable;  Aliessa Court Ordered Individuals;  Individuals enrolled in partial benefit programsPACE; and •  Individuals enrolled in both Medicare and Medicaid who have Comprehensive Third Party Insurance. Medicare-Medicaid beneficiaries who are in Medicare fee-for-service and meet the eligibility criteria above will be eligible for Passive Enrollment beginning January 1, 2014, unless they elect to opt out of the Demonstration, as discussed in C.2 below. Those beneficiaries who are enrolled in a Medicare Advantage plan that is operated by the same parent organization that operates a Demonstration Special Needs Plan will also be eligible for Passive Enrollment into the Demonstration Plan operated by the same parent organization beginning January 1, 2014. Eligible beneficiaries institutionalized individuals;  Individuals enrolled in Health Homes;  Individuals assigned to a Medicare Advantage plan that is operated by a parent organization that is not offering a Demonstration Plan may enroll into CMS Accountable Care Organization (ACO) as of the Demonstration if point in time they elect to disenroll from their current Medicare Advantage planwould otherwise be included in the passive enrollment phase;  Individuals participating in the CMS Independence at Home demonstration; and  Individuals enrolled in Employer or Union Sponsored coverage for employees or retirees.

Eligible Populations. The Demonstration will be available to individuals who meet all of the following criteria: •  Age 21 and or older at the time of enrollment; • Entitled to  Eligible for full benefits under Medicare Part A A, and enrolled under Medicare Parts B and D, and receiving full Medicaid benefits. (This includes individuals who are eligible for Medicaid through expanded financial eligibility limits under a 1915(c) waiver or who reside in a nursing facility and have a monthly patient pay amount.); and • Enrolled  Reside in the Medicaid Aid to the Aged, Blind, and Disabled (AABD) category of assistance. Eligible populations include: • Beneficiaries who meet all other a Demonstration criteria and are in the following Medicaid 1915(c) waivers: o Persons who are Elderly; o Persons with Disabilities; o Persons with HIV/AIDS; o Persons with Brain Injury and o Persons residing in Supportive Living Facilities. • Individuals with End Stage Renal Disease (ESRD) at the time of enrollmentregion. The following populations will be excluded from enrollmentenrollment in the Demonstration: •  Individuals under the age of 21; • 21  Individuals receiving developmental disability institutional previously disenrolled due to Special Disenrollment1 from Medicaid managed care  Individuals not living in a Demonstration region  Individuals with Additional Low Income Medicare Beneficiary/Qualified Individuals (ALMB/QI)  Individuals without full Medicaid coverage (spend downs or deductibles)  Individuals with Medicaid who reside in a State psychiatric hospital  Individuals with commercial HMO coverage  Individuals with elected hospice services To avoid duplication of services, individuals enrolled in the MI Choice waiver program (a 1915(c) waiver) and related Money Follows the Person (MFP) program, or who the Program for All-inclusive Care for the Elderly (PACE) may choose to participate in the HCBS waiver for Adults with Developmental Disabilities; • The Medicaid Spend-down population; • Beneficiaries in the Illinois Medicaid Breast and Cervical Cancer program; • Individuals enrolled in partial benefit programs; and • Individuals enrolled in both Medicare and Medicaid who have Comprehensive Third Party Insurance. Medicare-Medicaid beneficiaries who are in Medicare fee-for-service and meet the eligibility criteria above will be eligible for Passive Enrollment beginning January 1Integrated Care Program, 2014, unless they elect to opt out of the Demonstration, as discussed in C.2 below. Those beneficiaries who are enrolled in a Medicare Advantage plan that is operated by the same parent organization that operates a Demonstration Plan will also be eligible for Passive Enrollment into the Demonstration Plan operated by the same parent organization beginning January 1, 2014. Eligible beneficiaries enrolled in a Medicare Advantage plan that is operated by a parent organization that is not offering a Demonstration Plan may enroll into the Demonstration but only if they elect to disenroll from their current MI Choice, MFP, or PACE. Services similar to those offered through the MI Choice waiver or PACE will be offered through the Demonstration. Medicare-Medicaid enrollees that are enrolled in Medicaid-only managed care are eligible and will be passively enrolled in the Demonstration. 1 The ICO may initiate special disenrollment requests for behaviors as defined in 42 CFR 438.56. Populations Excluded from Passive Enrollment As described below, the Demonstration will include passive enrollment in certain instances into ICOs when individuals do not make an active choice about enrollment into the Demonstration. Individuals in the following categories will not be eligible for passive enrollment in the Demonstration, but may choose to participate through opt-in enrollment. Those electing to participate in the Demonstration must disenroll from the program from which they are currently receiving services.  Individuals enrolled in MI Choice, MFP, or PACE  Individuals enrolled in an employer sponsored Medicare Advantage health plan. Education will be emphasized for individuals in this population.